Research ArticlePrevalence of Coronal Pulp Stones and ItsRelation with Systemic Disorders in Northern IndianCentral Punjabi Population

Sandeep Kumar Bains,1 Archana Bhatia,2 Harkanwal Preet Singh,3

Swati Swagatika Biswal,4 Shashi Kanth,5 and Srinivas Nalla6

1 Department of Oral Medicine and Radiology, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India2Department of Periodontics, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India3 Department of Oral Pathology and Microbiology, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India4KLES Institute of Dental Sciences, Bangalore, Karnataka, India5 Department of Maxillofacial Surgery, Azamgarh Dental College, Azamgarh, Uttar Pradesh, India6Department of Orthodontics and Dentofacial Orthopedics, Al Badar Rural Dental College and Hospital, Naganhalli Road,Daryapur, Gulbarga, India

Correspondence should be addressed to Harkanwal Preet Singh; hkps0320@gmail.com

Received 9 January 2014; Accepted 20 March 2014; Published 22 April 2014

Academic Editors: F. D. Nunes and D. Wray

Copyright © 2014 Sandeep Kumar Bains et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Aim. To estimate the prevalence of coronal pulp stones in the molar teeth of dental outpatients of Sunam, Sangrur district, Punjab,India, to report any association between occurrence of pulp stones with age, gender, dental arch, side, and dental status and tofind out correlation between pulp stones with dental and systemic diseases.Materials and Methods. 500 routine dental outpatientswithin age group of 18–67 years were involved in the study. Molar bitewing of left and right side of each patient was taken withXCP bitewing instrument and size 2 film. The presence or absence of pulp stones was recorded. Chi-square analysis was used torecord the prevalence of pulp stones and to compare it with demographic and systemic factors. Results. Overall prevalence of pulpstones was 41.8%. Pulp stones were significantly higher in maxilla (11.59%) thanmandible (6.54%), left side than right side, and firstmolar than other molars. Higher numbers of pulp stones were recorded in patients with cardiovascular disease (38.89%) than withcholelithiasis and renal lithiasis. Conclusion. Pulp stones were higher in maxillary arch than mandibular arch and in females thanmales. Cardiovascular patients had higher number of pulp stones than other groups.

1. Introduction

Pulp stones are foci of calcification in the pulp of tooth.Calcification can occur in the dental pulp as discrete calcifiedstones or as diffuse form that can occur freely in thepulp tissue or is attached to or embedded into dentin [1].Depending on their microscopic structures, pulp stones havebeen classified into true or false form. They are not clinicallyapparent but are common radiographic findings [2].

They have variable radiographic appearance; they maybe radiopaque structure within the pulp chamber or in theroot. They do not have uniform shape or number. They may

be round or oval, and some pulp stones inhabit most of thepulp chamber. Some may be large as 2 or 3mm in diameter.Only these large calcified concretions are radiographicallydiscernible. Pulp stones occur most commonly in molars,although they occur in all tooth types [2]. Healthy, deceased,and even unerupted teeth can have pulp stones [3]. Half theteeth of young people and in almost all the teeth of peopleolder than fifty years of age have pulp stones which areprobably apparent microscopically [2]. Pulp degeneration,inductive interactions between epithelium and pulp tissue,age, circulatory disturbances in the pulp, nanobacteria [4],orthodontic tooth movements, idiopathic factors, genetic

Hindawi Publishing CorporationISRN DentistryVolume 2014, Article ID 617590, 5 pageshttp://dx.doi.org/10.1155/2014/617590

2 ISRN Dentistry

Table 1: Prevalence of pulp stones and dental arches.

Maxilla Mandible 𝑃 valueTotal teeth 2690 2643

0.001Pulp stones 312 173Percentage (%) 11.59 6.54

Table 2: Prevalence of pulp stones and tooth type.

Tooth type Total teeth Pulp stones Percentage 𝑃 value16 468 78 16.7%

0.0001

17 472 53 11.2%18 394 7 1.8%26 471 99 21%27 483 67 13.87%28 402 8 2%36 440 40 9.09%37 452 34 7.5%38 424 6 1.4%46 440 51 11.6%47 459 33 7.2%48 428 9 2.1%Total 5333 485 9.09%

predisposition [1], fluoride supplementation [5], and Marfansyndrome [6] are the few factors which are implicated inpulp stones formation. Their formation may be associatedwith long standing irritants such as caries, deep fillings, andchronic inflammation. Some authors suggest that pulp stonesare a feature of an irritated pulp, attempting to repair itself[1].

Pulpal pain is one of the frequent symptoms associatedwith pulp stones. The pain may vary from mild to severe[4, 7]. They can cause obstruction of the root canals whichleads to endodontic failure [8]. Calcific atheromas and thecalcification of dental pulp may have a similar pathogenesisso the routine dental radiographs may be useful as a rapidscreening method for early identification of potential cardio-vascular diseases. So, oral andmaxillofacial radiologymay behelpful in screening for cardiovascular diseases [9].

The present study aimed at estimating the prevalence ofpulp stones by bitewing radiographs. This study also aimedat correlating the prevalence of pulp stones with that of age,gender, dental status, dental diseases, and systemic diseases.

2. Materials and Method

This study was conducted in the Department of OralMedicine and Radiology, Guru Nanak Dev Dental College,Hospital & Research Institute, Sunam, over an 18-monthperiod. 500 routine dental outpatients within age group of18–67 years were involved in the study. Ethical permissionwas taken before the commencement of study. Patientswith grossly destructed teeth, teeth with metal crowns, andextensive metallic restoration and poor quality radiographswere excluded from study sample.

Figure 1: Pulp stones in 16, 17, 46, and 47 teeth.

Figure 2: Pulp stones in 26, 27, and 36 teeth.

The patients were informed regarding the study and aninformed written consent was obtained. A case history Per-forma was designed to obtain patient information regardingage, sex, periodontal status, history of orthodontic treatment,dental status (caries, restoration, attrition), and systemicdiseases. Patients were divided into 5 age groups of 100 each,that is, 18–27 years, 28–37 years, 38–47 years, 48–57 years,and 58–67 years. Patients were made to wear lead apron andthyroid collar and sit on the chair. Head rest was adjusted tosupport and position the patient’s head so that the upper archis parallel to the floor andmid-sagittal plane is perpendicularto the floor. The extension cone paralleling (XCP) bitewinginstrument was assembled in patient’s mouth with film andthe patient was asked to bite on the bite block. Tube head wasadjusted +10 degree to the external guide ring to make thebeam parallel with the occlusal planemaintaining the 16-inchof focal spot to object distance. Molar bitewing radiographsof right and left side of each patient were taken usingintraoral radiographic unit operating at 70 kilovoltage peakand 8 milliamperes by standard exposure parameters. Filmswere exposed. Exposed films were manually processed understandardized processing conditions in light proof dark roomand were dried. Dried films thus obtained were viewed byusing X-ray viewer and magnifying glass for the presence orabsence of pulp stones (Figures 1, 2, 3, 4, and 5). Data obtainedwas tabulated and statistically analyzed with application ofStatistical Package for the Social Sciences (SPSS) version 5.0

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Table 3: Prevalence of pulp stones in relation to age group of males and females.

Age groups (years)Total patients = 500

𝑃 valueFemale MaleTotal patients Patient with pulp stones Total patients Patient with pulp stones

18–27 48 14 (29.2%) 52 25 (48.1%)

0.05

28–37 45 16 (35.6%) 55 26 (47.3%)38–47 51 24 (47.1%) 49 19 (38.8%)48–57 58 22 (37.9%) 42 18 (42.9%)58–67 55 22 (40.0%) 45 23 (51.1%)Total 257 98 (38.1%) 243 111 (45.7%)

Table 4: Prevalence of pulp stones and dental status in males (max. and mand. arch).

ArchDental status

𝑃 valueTooth type Attrition Periodontal pathology Carious Restored

Total teeth PS Total teeth PS Total teeth PS Total teeth PS

Max.1st M 21 3 (14.2) 147 37 (25.2) 37 2 (5.4) 24 6 (25)

0.37

2nd M 13 1 (7.6) 100 21 (21) 36 3 (8.3) 25 6 (24)3rd M 7 1 (14.2) 24 1 (4.1) 24 1 (4.1) 13 1 (7.76)

Mand.1st M 17 3 (17.6) 147 18 (12.2) 58 4 (6.8) 41 4 (9.7)2nd M 15 1 (6.6) 143 15 (10.4) 47 2 (4.2) 50 6 (12)3rd M 9 1 (11.1) 28 1 (3.5) 47 1 (2.1) 24 1 (4.1)

Figure 3: Pulp stones in attrited, restored, and periodonticallyinvolved teeth.

Figure 4: Pulp stones in periodontically involved teeth.

Figure 5: Pulp stones in carious teeth.

using chi-square test and Fisher’s exact test. P value less than0.05 was considered statistically significant.

3. Results

Overall prevalence of pulp stones in both the gender was41.8% (209/500) and in teeth was 9.09%. Out of 257 males,98 had pulp stones and out of 243 females, 111 had pulpstones. Pulp stones were significantly higher in maxilla thanmandible (Max. = 11.59%,Mand. = 6.54%) (Table 1) (Figure 1).Pulp stones were higher in left side than right side andthey were significantly higher in 26 (21%). Pulp stones werehigher in the first molar than the second and third molar(Table 2). Pulp stones were significantly higher in 17, 26,37, and 46 of females than males. The age group from 58–67 years showed higher pulp stones as compared to othergroups (46.05%); difference was statistically nonsignificant

4 ISRN Dentistry

Table 5: Prevalence of pulp stones and dental status in females (max. and mand. arch).

Dental status𝑃 value

Tooth type Attrition Periodontal pathology Carious RestoredTotal teeth PS Total teeth PS Total teeth PS Total teeth PS

Max.1st M 14 4 (26.8) 106 25 (23.6) 34 4 (11.8) 29 4 (13.7)

0.23

2nd M 10 2 (20) 88 21 (23.8) 34 2 (5.8) 14 2 (14.2)3rd M 7 1 (14.2) 26 2 (7.7) 30 2 (6.6) 7 1 (14.2)

Man.1st M 14 5 (35.7) 117 19 (16.2) 64 4 (6) 40 8 (20)2nd M 13 3 (23) 103 12 (11.6) 31 3 (9.6) 43 1 (2)3rd M 5 1 (20) 25 1 (4) 39 2 (5) 22 1 (4.5)

Table 6: Prevalence of pulp stones in orthodontically treatedpatients.

Orthodontically treated patients𝑃 value

Total Pulp stonesMale 16 1 (6.25) 1Female 14 1 (7.1)

(Table 3). The prevalence of pulp stones in attrited teeth was(male = 12.19%, female = 26.22%) 18.18% (Tables 4 and 5).

The prevalence of pulp stones in periodontal pathol-ogy teeth (male = 15.78%, female = 17.20%) was 16.41%. Theprevalence of pulp stones in carious teeth (male = 5.22%female = 7.32%) was 6.23%. The prevalence of pulp stones inrestored teeth (male = 13.55%, female = 10.96%) was 12.34%(Tables 4 and 5).

The prevalence of pulp stones in orthodontically treatedpatients (male = 6.25%, female = 7.14%) was 6.66% (Table 6).The prevalence of pulp stones in arteriosclerotic (male = 50%,female = 25%) patients was 38.88%. The prevalence of pulpstones in renal stone (male = 20% and female = 14.2%)patients was 16.66%. The prevalence of pulp stones incholelithiasis (male = 0% and female = 25%) patients was 10%(Table 7).

4. Discussion

The present study comprised of 500 patients, 243 females and257 males within age group of 18–67 years. Molar bitewingradiographs of right and left side of each patient were takenand evaluated by maxillofacial radiologist for presence ofpulp stones.

The prevalence of pulp stone calculated in this study was41.8% and females exhibited higher pulp stones than maleand maxillary teeth had higher pulp stones than mandibularteeth which are in accordance with other studies conductedby Ranjitkar et al. [1], Tamse et al. [10], and Goga et al. [11].The prevalence of pulp stones in this study was found to behigher in the first molar than in the second molar which isin agreement with other investigators [1, 10, 12]. A plausibleexplanation is that the early eruption of the first molar willexpose them for long period of time, to more degenerativechanges, thus confirming that the calcification of the pulpincreases with the time [13]. Al-Nazhan andAl-Shamrani [13]

concluded that most attributable reason could be that as ageadvances the structure of the normal pulp varies.This usuallyleads to a progressive decrease in the number of pulp cells aswell as gradual increase in mucopolysaccharides and fibrouselements leading to calcification. In the present study, 58–67years group showedhigher pulp stoneswhichwas in harmonywith Sayegh and Reed study [14].

Our study showed that 16.41% teeth with pulp stones wereassociated with periodontal pathology. Reports dealing withthe effect of periodontal disease on the pulp tissue showed aclose relationship between the presence of pulp calcificationsand periodontal disease. Sheykhrezaee et al. concluded thatperiodontal disease can lead to fibrosis and calcification [15].Subay et al. examined sixty teeth with various degrees ofperiodontal disease and found pulp calcification in 78% ofteeth and suggested that periodontal disease interferes withblood supply and nutrition of the pulp causing decrease incellular elements and increase in calcification [16].

The present study revealed that out of 143 attrited teeth,26 teeth showed pulp stones which were less than reportedby Al-Nazhan and Al-Shamrani [13]. Studies have shownthat irritants like attrition and caries can lead to deleteriousinfluence on the pulp [9]. Spouge reported that the physicalabrasiveness of the diet and the highly developed musclesof mastication account in part for the high rate of attrition.Irritation in form of attrition causes circulatory disturbancesand thrombosis which mineralizes leading to pulp stoneformation [13].

Carious lesions stimulate inflammatory changes withinpulp leading to secondary dentin formation and increasedcalcification [5]. The recent literature suggests that pulpstones are a feature of an irritated pulp, an attempt torepair itself [1]. In our investigation we observed that outof 481 carious teeth, 30 (6.2%) teeth showed pulp stones.However, prevalence was low as noticed by Al-Nazhan andAl-Shamrani [13]. It is known that trauma in the form ofrestorative procedure can cause capillary thrombosis and/orvascular wall damage which on mineralization can lead toformation of pulp stone. In this study, out of 332 restoredteeth, 41 (12.3%) teeth had pulp stones.Thiswas in accordanceto Al-Nazhan and Al-Shamrani.

Sayegh and Reed [14] concluded that systemic variationssuch as arteriosclerosis and renal lithiasis can be consideredas factors predisposing to pulpal calcification which was laterconfirmed by Moura and Paiva in his radiographic study.

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Table 7: Prevalence of pulp stones and systemic diseases.

Systemic diseases𝑃 valueAtherosclerosis Renal stones Cholelithiasis

Total Pulp stones Total Pulp stones Total Pulp stonesMale 10 5 (50%) 5 1 (20%) 6 0 0.367Female 8 2 (25%) 7 (14.2) 4 1 (25%)

Edds et al. found a significant (75%) relationship betweenpreexisting cardiovascular disease and pulp stones. In ourstudy, out of 18 arteriosclerotic patients, 7 (38.8%) had pulpstones which is less than that reported by Edds et al. [9].

Out of 12 renal stone patients, 2 (16.67%) had pulpstones and out of 10 cholelithiasis patients 1 had pulp stone(10%). Stafne and Szabo [17] suggested that pulp stones arenot directly responsible for the production of renal stonesand gall stones. However, Ciftciouglu et al. proposed thatnanobacteria may induce pulp calcification and kidney stoneand gall stone formation [4].

So, we suggest that patients with pulp stones have highpropensity to develop cardiovascular or cholelithiasis. So,such patients should be screened to asses such complicationsat early stages. Orthodontic force application may produceperiodontal inflammatory reaction. Forces can cause odon-toblastic layer degeneration due to circulatory disturbancesin human pulp tissue causing calcification. The present studyshowed that two patients (6.66%) had pulp stones out of 30orthodontically treated patients. Delivanis found 2 patients(4.34%) having pulp calcification out of 46 orthodontictreated patients. Subay et al. [16] found 17.5% pulp stones inpatients undergoing orthodontic treatment. They concludedin their study that extrusive forces applied to teeth do notcause significant pathological changes in human pulp tissue.

5. Conclusion

Considering the fact that this is the first study in Punjabipopulation that may provide a preliminary data regardingthe usefulness of bitewing radiography for coronal pulp stoneestimation and their implication in endodontic treatmentand its relationship with pain, this study may be used as arapid screening method for early identification of potentialcardiovascular diseases. It may serve as an adjunct in forensicodontology. However, large scale longitudinal studies arerequired to substantiate the findings obtained in this study.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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[14] F. S. Sayegh and A. J. Reed, “Calcification in the dental pulp,”Oral Surgery, Oral Medicine, Oral Pathology, vol. 25, no. 6, pp.873–882, 1968.

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